Inside Health

CASES; Checking the Right Boxes, but Failing the Patient

By DENA RIFKIN, M.D.

Published: November 17, 2009

The voice on the phone was authoritative, even brusque. A father was calling our after-hours line to ask about his teenage daughter.

''She's got another headache,'' he said, as I recall. ''I'm going to the pharmacy, just wanted your advice on what strength of Tylenol to get her.''

Those opening lines did not admit much room for questions. I knew neither him nor his daughter, but there seemed to be little margin for error in my response. I could almost hear his foot tapping, waiting for the answer.

I hesitated. Who is this young woman? Why is her father calling about a simple headache?

I began to ask questions. Yes, his daughter had headaches every now and then. No, this one seemed a bit worse, that's all. He wouldn't even have called, but he wasn't sure if Tylenol was safe, now that she was breast-feeding.

Breast-feeding?

Yes, yes, there was a new baby, just a few days old. Yes, there had been some problem with the pregnancy and delivery -- something about blood pressure -- but she had come home just fine. Could I just tell him the right dose?

I sent the young woman and her father to the emergency room, and she was admitted to the hospital with severe pre-eclampsia, a rare but life-threatening postpartum complication.

It has been 10 years since the Institute of Medicine's seminal report on deaths caused by medical errors (numbering at least 44,000 a year). Since then, there has been tremendous focus on how many mistakes physicians and hospitals make, how much they cost and how to prevent them.

The response at most hospitals has been brisk and multifaceted. Hospital accreditation committees now audit charts for outdated abbreviations and proper signing of notes. Electronic prescription systems are rapidly becoming the norm. Pay-for-performance interventions by insurers promise to reward those who make the grade and to refuse payment to those whose treatments cause complications like hospital-acquired infections.

I do not dispute the need for these interventions. There is no doubt that hospitals are powerful and dangerous places, that ''best practices'' are not always followed and that the so-called polypharmaceutical approach -- a drug for every ailment a patient may have -- offers endless opportunity for adverse reactions.

An accessible and informative electronic medical record might have prevented my near-miss just as effectively as my questions did. (Under the vanished health care system in which doctors were available for their own patients 24 hours a day, this particular kind of error would have been all but impossible.)

None of these interventions, however well meant, address a fundamental problem that is emerging in modern medicine: a change in focus from treating the patient toward satisfying the system. The effects of focusing physicians' attention on benchmarks and check boxes are not, I think, to the patient's advantage.

A close family member was recently hospitalized after nearly collapsing at home. He was promptly checked in, and an electrocardiogram was done within 15 minutes. He was given a bar-coded armband, his pain level was assessed, blood was drawn, X-rays and stress tests were performed, and he was discharged 24 hours later with a revised medication list after being offered a pneumonia vaccine and an opportunity to fill out a living will.

The only problem was an utter lack of human attention. An emergency room physician admitted him to a hospital service that rapidly evaluates patients for potential heart attacks. No one noted the blood tests that suggested severe dehydration or took enough history to figure out why he might be fatigued.

A doctor was present for a few minutes at the beginning of his stay, and fewer the next day. Even my presence, as a family member and physician, did not change the cursory attitude of the doctors and nurses we met.

Yet his hospitalization met all the current standards for quality care.

As a profession, we are paying attention to the details of medical errors -- to ambiguous chart abbreviations, to vaccination practices and hand-washing and many other important, or at least quantifiable, matters.

But as we bustle from one well-documented chart to the next, no one is counting whether we are still paying attention to the human beings. No one is counting whether we admit that the best source of information, the best protection from medical error, the best opportunity to make a difference -- that all of these things have been here all along.

The answers are with the patients, and we must remember the unquantifiable value of asking the right questions.